2. PPP(Public PrivatePartnership)architecture and performance ledto the following PPP (PublicPrivate Partnership)framework Government(Public)
2. PPP (Public) Up to 95% ofexpenses byGovernmentcosts ofLeadership, Technology(Process, Medical
Is not Charisma, Public Relations, Showmanship Is performance consistent behavior and trustworthiness Is Thinking, Doing and Communicating Is setting Direction, Aligning and Motivating Is creating an environment of continuous learning Learning doesn‟t end with school or college You must learn throughout you life - never cease to be a student
Single toll free number „1-6-6-9‟ accessible on land and mobile phones
Unique Emergency Response Center staffed with trained Communication, Medical and Police personnel
Computer Telephony Integration Voice Loggers GIS / Maps GPS / AVLT Mobile Communication Application software for Sense, Reach and Care ePCR (Electronic Patient Case Record) Form
Ambulance design based on best
Pre-hospital Care / Emergency Medicine Training in collaboration
1 in 5 people visited the emergency department in 2007 (Centers for Disease Control and Prevention, 2010) Emergency care represents less than 3% of the nations $2.1 trillion in health care expenditures caring for 120 million annually Emergency physicians expect ER visits to increase with health care reform, due to growing physician shortages (ACEP, 2010)
NPs in EDs for over 4 decades ◦ Emergency Departments ◦ Fast Tracks ◦ Urgent Cares NPs/PAs cared for 13% of all ED patients (Am J Emerg Med, 2005) New Models of Care ◦ Rapid Triage ◦ Rapid Exams ◦ Rapid Disposition
2006 - Emergency Nurses Association embarked on Delphi Study (52 participants completed all three rounds) Competencies include knowledge, behaviors, and skills an entry- level NP should have in order to practice in emergency care. Competencies are intended to supplement the NONPF core competencies for all nurse practitioners as well as population- focused NP competencies NP practice may differ due to: ◦ variations in state regulation ◦ practice setting ◦ employment arrangement ◦ as a result of increases knowledge and/or experience
2008 - Consensus Panel ◦ American Association of Colleges of Nursing (AACN) ◦ American Academy of Emergency Medicine (AAEM) ◦ American Academy of Nurse Practitioners (AANP) ◦ American College of Emergency Physicians (ACEP) ◦ American College of Nurse Practitioners (ACNP) ◦ American Nurses Association (ANA) ◦ American Nurses Credentialing Center (ANCC) ◦ Board of Certification for Emergency Nursing (BCEN) ◦ Commission on Collegiate Nursing Education (CCNE) ◦ Emergency Nurses Association (ENA) ◦ National Council of State Boards of Nursing (NCSBN) ◦ National Organization of Nurse Practitioner Faculties (NONPF)(In press: Nurse Practitioner Delphi Study: Competencies for Practice in Emergency Care. Journal of Emergency Nursing Sept 2010)
EMS ( ) ” EMS ( )
Procedure off line) procedure Procedure off line) Procedure on line)
. ) . Scene size up) Triage) Dispatcher assessment) . ) . Primary survey) . Secondary survey) . Adjunct investigation with basic interpretation) CXR, CT, EKG, and Ultrasonography: FAST . Focus assessment) . Laboratories with interpretation) electrolyte, cardiac enzyme . (Initial diagnosis)
Organ danger presentation) ) Weakness Local severe pain High fever GI bleed Hemoptysis Hematuria Acute abdomen Complications of pregnancy Dehydration o Infant hypothermia Urgent condition) ). Hyperventilation. Electrolyte imbalance. Epitaxis. Drug addiction & withdrawal. Emergency psychosis
1. Triages patients‟ health needs/problems. 2. Completes specified medical screening examination. 3. Responds to the rapidly changing physiological status of emergency care patients. 4. Uses current evidence-based knowledge and skills in emergency care for the assessment, treatment, and disposition of acute and chronically ill and injured patients.
5. Specifically assesses and initiates appropriate interventions for violence, neglect, and abuse. 6. Specifically assesses and initiates appropriate interventions and disposition for suicide risk. 7. Assesses patient and family for levels of comfort and initiates appropriate interventions. 8. Recognizes, collects, and preserves evidence as indicated
9. Orders and interprets diagnostic tests. 10. Orders pharmacologic and non-pharmacologic therapies. 11. Orders and interprets electrocardiograms. 12. Orders and interprets radiographs. 13. Assesses response to therapeutic interventions. 14. Documents assessment, treatment, and disposition.
15. Functions as a direct provider of emergency care services. 16. Directs and clinically supervises the work of nurses and other health care providers. 17. Participates in internal and external emergencies, disasters, and pandemics. 18. Maintains awareness of known causes of mass casualty incidents and the treatment modalities required for emergency care. 19. Acts in accordance with legal and ethical professional responsibilities (e.g., patient management, documentation, advance directives).
20. Assesses and manages a patient in cardiopulmonary arrest. 21. Assesses and manages airway. 22. Assesses and obtains advanced circulatory access. 23. Assesses and manages patients with disability. 24. Assesses and manages procedural sedation patients. ◦ (See ENA/ACEP joint position statement – www.ena/org)
25. Performs ultraviolet examination of skin and secretions. 26. Treats skin lesions. 27. Injects local anesthetics. 28. Performs nail trephination. 29. Removes toe nail(s).
30. Performs a nail bed closure. 31. Performs closures (e.g., single layer, multiple, staple, adhesive). 32. Revises a wound for closure. 33. Debrides minor burns (e.g., non-adhering blister). 34. Incises, drains, irrigates, and packs wounds.
58. Performs radio communication with prehospital units. 59. Interprets patient diagnostics as communicated by prehospital personnel. 60. Removes foreign bodies.
Graduate Programs (Masters, Post " Masters, DNP) Programs with Emergency Concentration ◦ Uni of Southern Alabama – Mobile, AL ◦ Emory – Atlanta, GA ◦ Loyola – Chicago, IL ◦ Uni of Florida - Jacksonville, FL ◦ Uni of Texas, Houston, TX ◦ Uni of Texas, Arlington, TX ◦ Uni of Virginia – Charlottesville, VA ◦ Vanderbilt – Nashville, TN
GRADUATE PROGRAM ◦ FNP Program – Consensus Model Document 2008 EDs require “family across the life span” ACNP Program– usually no pediatric component CERTIFICATION ◦ FNP (e.g. ANCC, AANP) AANP does not support the DNP equivalency exam – this is an academic degree not a “clinical” option ◦ Specialty Certification BCEN Needs Assessment completed – to ENA BOD Summer 2010 for final recommendations (cert and/or portfolio) PREVIOUS EXPERIENCE ◦ Staff nurse (with BLS, ACLS, TNCC, ENPC) ◦ Certified Emergency Nurse (CEN) certified ◦ On-the-job training (e.g., suturing, minor procedures) ◦ Relevant continuing education
Graduation from an accredited program ◦ Emergency concentration preferred FNP Certification Exam ◦ Specialty certification and/or portfolio option (TBA) ◦ Competency skills checklist (graduate program) Application Process ◦ Resume Submitted RN License/NP License Prescriptive Authority/DEA License Panel Interview – EDMDs/NPs/PAs and Staff Medical Staff Privileges – may take up to 6 mo
(n = 6279) NP – avg. 9 yrs NP experience Most Common Specialties ◦ FNP (54.5%) ◦ Adult (20.4%) Practice ◦ Community practice < 25,000 (17%) ◦ Communities of > 250,000 (39%) Settings ◦ Private physician practices (30.3%) ◦ Hospital-based outpatient clinics (11.6%) ◦ Hospital inpatient settings (9.8%) Goolsby, M.J. (2009) Journal of the American Academy of Nurse Practitioners, 21, 186–188.
RN/Tech (vital signs) NP/PA medically screens patient and then determines level (5-level triage) B. High risk situation is a patient you would put in your last open bed C. Resources: Count the number of differentA. Immediate life-saving intervention Severe pain is determined types of resources, not the individual tests or required by clinical observation x-rays (examples: CBC, electrolytes and coags (apneic, pulseless, severe respiratory and/or patient rating of equals one resource; CBC plus chest x-raydistress, SPO2<90, acute mental status greater than or equal to 7 equals two resources). changes, or unresponsive) on 0-1/distress is 0 pain scale SOME PATIENTS WILL BE MEDICALLY SCREENED ABCDs - TO ED and SENT TO THE FAMILY WAITING ROOM – NP/PA ASSESSES, INITIATE (e.g. UTI) THEN DISCHARGED ORDER SETS – TO FAST TRACK – THEN DISCHARGED
Hospital vs. physician group role utilization Scope of practice (support to the physician with higher acuity patients) Resourcing of the role (add personnel to fast track) Ensuring medical staff at large is supportive and understanding of the role and scope of NPs/PAs. Compliance with medical staff oversight including Performance Improvement (PI) and Peer Review (PR).
32 million newly insured Americans by 2014 Predicted 40,000 primary care physician shortfall by 2020 Not enough emergency medicine residency trained MDs (Academic Emergency Medicine, 2008) Market forces virtually guarantee that more health providers will be using NPs and other "physician extenders" (Bauer, 2010)
The full integration of NPS... in many clinical areas will also enhance access. Decades of experience with NPs and several studies indicate that quality is not a problem with reforms that would allow NPs to provide more services. Patients like the care they receive from NPs at least as much as the care they receive from physicians. Consumers overall appreciation of NPs is extremely high. (Bauer, 2010; Edmunds, 2010; Office of Technology Assessment 1998; Safriet, 1992)
Peer-reviewed journal articles reinforce the Office of Technology Assessments conclusions in 1981NPs can be utilized in a significant portion of medical services ranging from 25% in some specialty areas to 90% in primary care with at least similar outcomes. Collaborative, team-based approaches to care including teams led by NPs should be actively promoted to reduce overall spending on healthcare. NPs can reduce costs without diminishing quality in the process.(Bauer, 2010; Edmunds, 2010; Office of Technology Assessment 1998; Safriet, 1992)